Case Report

Respirology Division

SPONDYLITIS TUBERCULOSIS AND CERVICAL

PARAVERTEBRAL ABSCESS WITH NUTRITIONAL MARASMIC

By:
Dina Kurniasih

Supervisor :
dr. Amiruddin L, Sp.A(K)
dr. Rahmawaty, M.Kes, Sp.A
 Background

• Tuberculosis (TB) is caused by Mycobacterium

tuberculosis, and is one of the oldest disease
in the world
• Spinal tuberculosis was discovered by Pott in
1776 and is the result of haematogenous
dissemination from a primary focus
•
 Etiologi
• The infection is caused by a
highly aerobic, alcohol-acid-
resistant, non-proteolytic
enzyme-producing bacillus

• The Mycobacterium
tuberculosis  Koch’s
bacillus (BK)
 Incidence

• 2016 occurred in the WHO South-East Asia Region (45%), the WHO African
Region (25%) and the WHO Western Pacific Region (17%);
• smaller proportions of cases occurred in the WHO Eastern Mediterranean
Region (7%), the WHO European Region (3%) and the WHO Region of the
Americas (3%)

• TB is the ninth leading cause of death worldwide

• An estimated 10.4 million people fell ill with TB in 2016
• 56% were in five countries: India, Indonesia, China, the Philippines and
Pakistan

• Globally, the TB mortality rate is falling at about 3% per year

• Most deaths from TB could be prevented with early diagnosis and
appropriate treatment.

WHO. Global Tuberculosis Report. 2017

The Lancet Infectious Diseases.2005
• Approximately 10% of patients with extrapulmonary tuberculosis
have skeletal involvement

• The spine is the most frequently affected area

• Spinal Tuberculosis is characterized by kyphotic deformity 
progressive destruction of the intervertebral space and adjacent
vertebral bodies  cold abscesses by extension to adjacent
ligaments and soft tissues, and neurological deficits due to
mechanical compression or direct effect of infection under neural
structures

• Thoracic region is most frequently affected (40% to 50% of the cases)

• Lumbar spine (35% to 45%)
• Cervical spine (10%
 Case Report

N
• 13 years 3 months • History cervical lymoh • No cough, no history
• Weakness his upper node enlargement of cough
extrimity • No pain in elderly • No dyspneu
• Since 2 months, • Become large and feel • Loss apetite
progressive pain • No vimitng
• Neck pain • No fever, no history of • Weigth loss
• Difficullt to move his fevr • Micturition and
neck defecation within
normal limit
 TB Contact • His grandma

• Appropiate his age

Milestone

Immunization • Basic immunization Completely

• BW : 25 kg
Nutrition • Height : 148 cm
• UA : 16 cm
Poornourished
 Physical examination

• Right Neck area : • Persitaltic

• Severely ill ulcus, pus, 3x3x0,2
• Poor nourished
normally
cm, necrotic area
• Full conciousness • Left anterior Colli • Liver and
• BP 100/60 mmHg enlarged lymph node spleen no
• PR 92x/min • I = 5x4x cm palpable
• RR 28x/min • II= 3x3x1 cm • Wasting on her
• BT 36.8o • Mobile, sharp extrimity
• BW 25 kg boreder, pus,
• Height 148 cm hiperemia, pain • Back : no
• GPH 154-1721 cm • Lung : normal limit deformity, no
• Cardiac : normally gibbus, but
painfull in
cervical area
Superior Extrimity :
• Motoric : 3 3
5 5
3 3
• Physiological reflex : normal normal
5 5
• normal normal
• Pathological reflex : negatif
• Hyposthesia in C5-Th1

Scoring TB :
Contact : 1 Fever : 0
Nutritional : 2 Cough : 0
Lymph Node Enlargement : 1 Mantoux test : not yet
Chest X Ray : 0
Total : 4
 Laboratory
CBC

• Hb 10,5 g / dl, • Na 144 mmol/L, • Routine stool and

• MCV 80 • K 4.3 mmol/L, urine rutine did
• MCH 27 • Cl 106 mmol/L. not show any
SGOT 21 U/L, abnormality
• wbc 9.500 / mm3
SGPT 14 U/L, findings.
• platelets 419. 000
/ mm3 • albumin 4.1
mg/dl, blood
sugar 80 mg/dl
• ureum 36 mg/dl,
kreatinin 0.42
mg/dl
 Chest X Ray

Showed : cor and pulmo within normal limit

 Working Diagnosis

• Abses paravertebra servical suspected

Spondilitys TB
• Paraparese Superior
• Nutritional marasmus
• Chronic by anemia disesase.
 Management
• IVFD KAEN 3B 12 gtt/mnt

• Ampicillin 500 mg / 6 hours / iv

• Gentamicin 50 mg / 12 hours / iv
• Paracetamol 250mg/8 hr/ iv (if BT ≥ 38,5 o C, and or pain scale ≥ 3 NRS)

• Management of severe malnutrition

• Stabilization phase day 1:
F75 : 8x 200 ml via NGT
B complex vitamin 1 tablet/24 hr/orally
Folic Acid 5 mg/orally
Vitamin A 200.000 IU orally
Vitamin C 50 mg/12 hr/oraly

Mantoux test
 Follow Up
Day Vital Sign Physical examination Management

3rd BP: 90/60 mmHg, Weakness upper Bed rest,

PR : 82 x / minute, extrimity, pain decrease IVFD
RR: 24 x / min no fever, no cough, and antibiotics
BT : 36,7˚ C nutrition management transtition
Pain Scale 1 NRS phase 1st days.
 MRI C -Spine

Summary :
Multiple Ostemomyelitis CV C2-C6 with paravertebra abscess, that compress thecal sac
Musculus and soft tissue abscess billaterally cervical mainly in left region
 Follow Up
Day Vital Sign Physical examination Management

4st BP: 90/60 mmHg, Weakness upper Bed rest,

PR : 88 x / extrimity, pain IVFD
minute, RR: 26x / decrease antibiotics
min no fever, no cough nutrition management transtition
BT : 36,5˚ C phase 2st days
Pain Scale 1 NRS Peripher Blood Smear
: OAT 4 Regimens :
Normositik INH 300 mg/24 hr/orally
normokrom Rifampicin 450 mg/24 hr/orally
Ferritine : Piraznamid 1000 mg/24 hr/orally
130,3 ng/mL Ethambutol 625 mg/24 hr/orally

BTA negative
 Mantoux Test

Mantoux Test Result

20 mm (postive)
 Follow Up
Day Vital Sign Physical Examination Management

10th Normall Weakness upper extrimity, Bed rest,

limit pain decrease IVFD
no fever, no cough antibiotics meropenem 500 mg/8
hr/iv
Pus culture result : nutrition management
rehabilitation phase
Klebsiella pneumoniae
Sensitive with meropenem OAT 4 Regimens :
INH 300 mg/24 hr/orally
Rifampicin 450 mg/24 hr/orally
Piraznamid 1000 mg/24 hr/orally
Ethambutol 625 mg/24 hr/orally

Plan : debridement
 Follow Up
Day Vital Sign Physical Examination Management

15th Normall Weakness upper extrimity, Bed rest,

limit pain decrease IVFD
no fever, no cough antibiotics meropenem 500 mg/8
hr/iv
Pus culture result : nutrition management
rehabilitation phase
Klebsiella pneumoniae
Sensitive with meropenem OAT 4 Regimens :
INH 300 mg/24 hr/orally
Rifampicin 450 mg/24 hr/orally
Piraznamid 1000 mg/24 hr/orally
Ethambutol 625 mg/24 hr/orally

Plan : debridement
 Follow Up
Day Vital Sign Physical Examination Management

20th Normall Weakness upper extrimity,

limit pain decrease
no fever, no cough
Neck area :
Necrotic ulcer, no pus
Decrease of size 91x0,5x0,2
cm)
Lymph node enlargement
decrease (1,5x1x0,5 cm)
Extrimity : 4-4
OAT 4 Regimens :
INH 300 mg/24 hr/orally
Rifampicin 450 mg/24 hr/orally
Piraznamid 1000 mg/24 hr/orally
Ethambutol 625 mg/24 hr/orally
Discharge
Plan to medic rehabilitation
 Definitive Diagnosis
• Spondilitis Tuberculosis
• Cervical Paravertebra Abscess (C1-C6)
• Superior Paraparese
• Nutritional Marasmic
• Anaemia by Chronic Diseases
 Prognosis
• Quo ad vitam : dubia
• Quo ad sanationem : dubia
 Discussion
Spinal TB  hematogenic spread from
>> lung and genitourinary
This Case
Late onset
Sahputra (2015) & Lee KY (2014) Didn’t find primary lesion
Report  mean onset 11,2 wks (4-24
weeks) Onset 1yr and 2 months
Idjema et al (2015)
Delayed diagnosis of spinal
tuberculosis 52%
 Symptoms

Symptoms most frequently presents

Idjema et al (2015)

backache (96.7%) This Case

weight loss (54.2%)
night sweats (39.9%) Paraparese
In total, 80 patients (29%)  this trias of symptoms Backache
fever (31.9%), Lymph node enlargement
generalized limb weakness and -numbness
(15.8%),
isolated limb weakness (11%)
(2.6%) had paraplegia
(1.1%) tetraplegia

Idjema et.al. 2015. Clinical Characteristics and diagnostic delay in Spinal Tuberculosis Patients in
Netherlands. Mycobat Dis. Volume 5
This case  weight loss, lymph node enlargement, TB score 5,
tuberculin test (+), contact TB (+)

Pus  Klebsiella pneumonie (+), BTA  (-)

Klebsiella pneumoniae spondylitis piogenik  2,3%
62,9%  vertebra lumbalis (Ji Kang, 2015)

MRI C- Spine  destruction in CV C2-C6, with hipointens

intraosseus lesion, smooth border Spinal Tubeculosis
Distinctive clinical findings of Pyogenic and Tuberculous
Spondylitis

Lee K. 2014. Comparison of Pyognic Spondylitis and Tuberculous Spondylitis.

Asian Spine J, 8(2) : 216-223
MRI Findings of Pyogenic Spondylitis and Tuberculous
Spondylitis

Lee K. 2014. Comparison of Pyognic Spondylitis and Tuberculous Spondylitis.

Asian Spine J, 8(2) : 216-223
 Management
Theory
Conservative management 
antimicrobial therapy & non
pharmacological treatments
Case
(physioherapy & immobilization) bed rest
Antibiotics
Surgical Management :
OAT
- to acquire bacteriological
- severe pain Nutritional therapy
- important abscess Drainage and abscess
- no response after appropriate debridement
antibiotics
- spine is deformed Anterior fusion
- prevented due to severe damage
- neurological paralysis
 Nutrition Management

Prevent and
Correct Treat Infection Food for catch up
Hypoglicemia
Improve Stimulation for
Prevent & Correct deficiency growth and
Hyponatremia micronutrients development
Prevent & Correct Provide food for Preparing for
Dehydration stabilization & rehabilitation at
Correct Electrolyte Transition home
Imbalance
 Summary

• A case of Tuberculosis spondylitis and cervical paravertebral abscess

with marasmic nutritional in 13 years and 3 months old boy has
been reported.

• The definitive diagnose was established based on history taking,

physical examination, tuberculin test and radiological findings. On
MRI C Spine showed multiple ostemomyelitis CV C2-C6 with
paravertebral abscess that supress thecal sac. And abscess ini
musculus and soft tissue in cervical region with tuberculin test was
positively (20 mm)

• The prognosis was dubious